This paper argues within the mental health services that people who are most disabled by mental illness, the severely mentally ill (SMI), should be afforded the highest priority, and that services should be provided in relation to need. For this to occur the priority groups need first to be defined. Second, if a service wishes to provide for all prevalent cases of people suffering from severe mental illness, then a systematic method of recording local information about these people is required, and this may draw upon information about patients who are in contact with health services, social services, family health services and who contact voluntary sector and other agencies. One approach to estimating the need for services for people with SMI is by using indicative norms for service requirements. Finally, managerial methods are proposed to monitor how far targeting services to the SMI occurs in clinical practice.

This paper concerns one of the four research projects developed during a training course in clinical epidemiology managed by the Lombardy training centers IREF. Objectives — To compare the recommandations for treatment concerning 9 vignettes derived from the Australian Quality Assurance Project. Setting — Six Mental Health Services of Regione Lombardia. Design and Participants — For each vignette, all psychiatrists working in the 6 Mental Health Services were asked to fill in a questionnaire about treatment location, psychopharmacology, psychotheraphy, priority between psychotherapy and psychopharmacology and degree of difficulty in answering. Results — 44 out of 52 target psychiatrists took part to the study. Remarkable variability for treatment location and psychotherapies; moderate variation for psychodrugs prescriptions and a good agreement for diagnoses were observed. In drugs prescription an eccess of association was observed. The most prevalent model of psychotherapy was the psychodynamic, followed by the cognitivebehavioural and the family-systemic. There was a tendency toward a flexible approach, as suggested by recommendations of different psychotherapeutic models according to the nature of the disorder. No case were judged very difficult; only in 3 cases a judgement of «somewhat difficult» was expressed by more than 20% (but less than 30%) of the psychiatrists. Conclusions — Studies of this type are very easy to carry out and give useful information for continuous training programs and Continuous Quality Improvement projects.

Objective - To compare psychiatric bed usage for major psychiatric illness in a fully community-centred psychiatric service (South Verona, Italy) with usage in a more conventional hospital-centred service (Canberra, Australia). Design - Registers of hospital admissions for schizophrenia and major affective illness in the three years 1986, 1987, 1988 were examined at each site. The characteristics, socio-demography and rates of admission, the duration of index admission and the rate of readmission in the subsequent twelve months were compared. Results - The community-centred service (South Verona) admitted fewer patients with schizophrenic and major affective illness but they appeared more severely ill, stayed longer and were more likely to be readmitted. The hospital-centred system (Canberra) used hospitals for a wider range of severity of major illness including good prognosis illness. Hospitalisation in Canberra was briefer and readmission less frequent. It appears that the hospital centred service was more willing to use beds for the initiation or stabilisation of treatment. The community based service did not lead to shorter hospital stay or less frequent readmission. Differences in the treated psychiatric morbidity in the populations overshadowed the effect of design of the service on usage. This difference in morbidity, concentrated in the younger age group, remains unexplained.